1992735815 NPI number — KRYSTAL L PUSSER OD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992735815 NPI number — KRYSTAL L PUSSER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUSSER
Provider First Name:
KRYSTAL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRAGG
Provider Other First Name:
KRYSTAL
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992735815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2817 REILLY ST
Provider Second Line Business Mailing Address:
WOMACK ARMY MEDICAL CENTER
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28310-7324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-907-8922
Provider Business Mailing Address Fax Number:
910-907-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2817 REILLY ST
Provider Second Line Business Practice Location Address:
WOMACK ARMY MEDICAL CENTER
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310-7324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-907-8922
Provider Business Practice Location Address Fax Number:
910-907-6069
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT001348 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000606537H . This is a "MEDICAID - RINCON" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1992735815 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000606537F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000606537G . This is a "MEDICAID- BORO" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 111065 . This is a "NATL VISION ADMIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 732348 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000606537D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000606537A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000606537E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08525 . This is a "SPECTERA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52484359 . This is a "STATE HEALTH PLAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00013749 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 511G701032 . This is a "GA MEDICARE GROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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